Yun-Dong Shen

Differences in Brain Adaptive Functional Reorganization in Right and Left Total Brachial Plexus Injury Patients

OBJECTIVE Total brachial plexus avulsion injury (BPAI) results in the total functional loss of the affected limb and induces extensive brain functional reorganization. However, because the dominant hand is responsible for more cognitive-related tasks, injuries on this side induce more adaptive changes in brain function. In this article, we explored the differences in brain functional reorganization after injuries in unilateral BPAI patients. METHODS We applied resting-state functional magnetic resonance imaging scanning to 10 left and 10 right BPAI patients and 20 healthy control subjects. The amplitude of low-frequency fluctuation (ALFF), which is a resting-state index, was calculated for all patients as an indication of the functional activity level of the brain. Two-sample t-tests were performed between left BPAI patients and controls, right BPAI patients and controls, and between left and right BPAI patients. RESULTS Two-sample t-tests of the ALFF values revealed that right BPAIs induced larger scale brain reorganization than did left BPAIs. Both left and right BPAIs elicited a decreased ALFF value in the right precuneus (P < 0.05, Alphasim corrected). In addition, right BPAI patients exhibited increased ALFF values in a greater number of brain regions than left BPAI patients, including the inferior temporal gyrus, lingual gyrus, calcarine sulcus, and fusiform gyrus. CONCLUSION Our results revealed that right BPAIs induced greater extents of brain functional reorganization than left BPAIs, which reflected the relatively more extensive adaptive process that followed injuries of the dominant hand.

Contralateral Peripheral Neurotization for Hemiplegic Upper Extremity After Central Neurologic Injury

BACKGROUND Central neurological injury (CNI) is a major contributor to physical disability that affects both adults and children all over the world. The main sequelae of chronic stage CNI are spasticity, paresis of specific muscles, and poor selective motor control. Here, we apply the concept of contralateral peripheral neurotization in spasticity releasing and motor function restoration of the affected upper extremity. OBJECTIVE A clinical investigation was performed to verify the clinical efficacy of contralateral C7 neurotization for rescuing the affected upper extremity after CNI. METHODS In the present study, 6 adult hemiplegia patients received the nerve transfer surgery of contralateral C7 to C7 of the affected side. Another 6 patients with matched pathological and demographic status were assigned to the control group that received rehabilitation only. During the 2-year follow-up, muscle strength of bilateral upper extremities was assessed. The Modified Ashworth Scale and Fugl-Meyer Assessment Scale were used for evaluating spasticity and functional use of the affected upper extremity, respectively. RESULTS Both flexor spasticity release and motor functional improvements were observed in the affected upper extremity in all 6 patients who had surgery. The muscle strength of the extensor muscles and the motor control of the affected upper extremity improved significantly. There was no permanent loss of sensorimotor function of the unaffected upper extremity. CONCLUSION This contralateral C7 neurotization approach may open a door to promote functional recovery of upper extremity paralysis after CNI.

Trial of Contralateral Seventh Cervical Nerve Transfer for Spastic Arm Paralysis

BACKGROUND Spastic limb paralysis due to injury to a cerebral hemisphere can cause long‐term disability. We investigated the effect of grafting the contralateral C7 nerve from the nonparalyzed side to the paralyzed side in patients with spastic arm paralysis due to chronic cerebral injury. METHODS We randomly assigned 36 patients who had had unilateral arm paralysis for more than 5 years to undergo C7 nerve transfer plus rehabilitation (18 patients) or to undergo rehabilitation alone (18 patients). The primary outcome was the change from baseline to month 12 in the total score on the Fugl–Meyer upper‐extremity scale (scores range from 0 to 66, with higher scores indicating better function). RESULTS The mean increase in Fugl–Meyer score in the paralyzed arm was 17.7 in the surgery group and 2.6 in the control group (difference, 15.1; 95% confidence interval, 12.2 to 17.9; P<0.001). With regard to improvements in spasticity as measured on the Modified Ashworth Scale (an assessment of five joints, each scored from 0 to 5, with higher scores indicating more spasticity), the smallest between‐group difference was in the thumb, with 6, 9, and 3 patients in the surgery group having a 2‐unit improvement, a 1‐unit improvement, or no change, respectively, as compared with 1, 6, and 7 patients in the control group (P=0.02). Transcranial magnetic stimulation and functional imaging showed connectivity between the ipsilateral hemisphere and the paralyzed arm. There were no significant differences from baseline to month 12 in power, tactile threshold, or two‐point discrimination in the hand on the side of the donor graft. CONCLUSIONS In this single‐center trial involving patients who had had unilateral arm paralysis due to chronic cerebral injury for more than 5 years, transfer of the C7 nerve from the nonparalyzed side to the side of the arm that was paralyzed was associated with a greater improvement in function and reduction of spasticity than rehabilitation alone over a period of 12 months. Physiological connectivity developed between the ipsilateral cerebral hemisphere and the paralyzed hand. (Funded by the National Natural Science Foundation of China and others; Chinese Clinical Trial Registry number, 13004466.)

Arthroscopic Distal Metaphyseal Ulnar Shortening Osteotomy for Ulnar Impaction Syndrome: A Different Technique

Ulnar impaction syndrome generally occurs with positive ulnar variance. The solution to the problem is to unload the ulnocarpal joint. Effective surgical options include diaphyseal ulnar shortening osteotomy, open wafer osteotomy, and arthroscopic wafer osteotomy. Recently, Slade and Gillon described an open procedure of ulnar shortening in the osteochondral region of the ulnar head. The procedure minimizes the risk of hemarthrosis and does not require hardware removal, which are problems with other surgical options. This article introduces a new arthroscopic technique of distal metaphyseal ulnar shortening osteotomy for ulnar impaction syndrome. This technique offers the advantages of minimizing surgical injury to the dorsal capsule of the distal radoulnar joint and so protects its stability.

Attenuation of brain grey matter volume in brachial plexus injury patients

Abstract Brachial plexus injury (BPI) causes functional changes in the brain, but the structural changes resulting from BPI remain unknown. In this study, we compared grey matter volume between nine BPI patients and ten healthy controls by means of voxel-based morphometry. This was the first study of cortical morphology in BPI. We found that brain regions including the cerebellum, anterior cingulate cortex, bilateral inferior, medial, superior frontal lobe, and bilateral insula had less grey matter in BPI patients. Most of the affected brain regions of BPI patients are closely related to motor function. We speculate that the loss of grey matter in multiple regions might be the neural basis of the difficulties in the motor rehabilitation of BPI patients. The mapping result might provide new target regions for interventions of motor rehabilitation.

Contralateral Lumbar to Sacral Nerve Rerouting for Hemiplegic Patients After Stroke: A Clinical Pilot Study

BACKGROUND Spasticity and muscle weakness are common severe neurologic sequelae after stroke. Contralateral peripheral neurotization has been applied successfully to promote motor function of the hemiplegic upper extremity in patients with central neurological injury. To our knowledge, we present the first report of contralateral lumbar to sacral nerve transfer for the lower extremities in hemiplegic patients after stroke. CASE DESCRIPTION Two patients were enrolled in the study. The first patient is a 57-year-old man who experienced permanent muscle weakness in his left leg after a right cerebral infarction. The second patient is a 42-year-old man who had spasticity and hemiplegia in both upper and lower limbs on the right side 32 months after a left cerebral hemorrhage. Both patients underwent contralateral lumbar-to-sacral nerve rerouting to improve lower-limb motor function. Twenty months after surgery, both patients experienced significant improvement in ambulatory status. CONCLUSIONS Although long-term follow-up and a randomized controlled trial are required, this study demonstrates the safety and possible benefits of contralateral lumbar-to-sacral nerve transfer for hemiplegic patients after stroke. This novel surgical approach could provide a new means for lower-limb motor functional recovery.

Nerve fascicle transfer using a part of the C-7 nerve for spinal accessory nerve injury

OBJECTIVE Spinal accessory nerve (SAN) injury results in a series of shoulder dysfunctions and continuous pain. However, current treatments are limited by the lack of donor nerves as well as by undesirable nerve regeneration. Here, the authors report a modified nerve transfer technique in which they employ a nerve fascicle from the posterior division (PD) of the ipsilateral C-7 nerve to repair SAN injury. The technique, first performed in cadavers, was then undertaken in 2 patients. METHODS Six fresh cadavers (12 sides of the SAN and ipsilateral C-7) were studied to observe the anatomical relationship between the SAN and C-7 nerve. The length from artificial bifurcation of the middle trunk to the point of the posterior cord formation in the PD (namely, donor nerve fascicle) and the linear distance from the cut end of the donor fascicle to both sites of the jugular foramen and medial border of the trapezius muscle (d-SCM and d-Traps, respectively) were measured. Meanwhile, an optimal route for nerve fascicle transfer (NFT) was designed. The authors then performed successful NFT operations in 2 patients, one with an injury at the proximal SAN and another with an injury at the distal SAN. RESULTS The mean lengths of the cadaver donor nerve fascicle, d-SCM, and d-Traps were 4.2, 5.2, and 2.5 cm, respectively. In one patient who underwent proximal SAN excision necessitated by a partial thyroidectomy, early signs of reinnervation were seen on electrophysiological testing at 6 months after surgery, and an impaired left trapezius muscle, which was completely atrophic preoperatively, had visible signs of improvement (from grade M0 to grade M3 strength). In the other patient in whom a distal SAN injury was the result of a neck cyst resection, reinnervation and complex repetitive discharges were seen 1 year after surgery. Additionally, the patients denervated trapezius muscle was completely resolved (from grade M2 to grade M4 strength), and her shoulder pain had disappeared by the time of final assessment. CONCLUSIONS NFT using a partial C-7 nerve is a feasible and efficacious method to repair an injured SAN, which provides an alternative option for treatment of SAN injury.

Brachialis muscle transfer for reconstructing digital flexion after brachial plexus injury or forearm injury

Restoration of digital flexion after brachial plexus injury or forearm injury has been a great challenge for hand surgeons. Nerve transfer and forearm donor muscle transfer surgeries are not always feasible. The present study aimed at evaluating the effectiveness of restoring digital flexion by brachialis muscle transfer. Ten lower brachial plexus- or forearm-injured patients were enrolled. After at least 12 months following surgery, the middle-finger-to-palm distance was less than 2.5 cm in six patients. In the other four patients with less satisfactory results, secondary tenolysis surgery was performed and the middle-finger-to-palm distances were reduced to 2.0–4.0 cm. The average grasp strength was 20 ± 4 kg. Elbow flexion was not adversely affected. In conclusion, brachialis muscle transfer is an effective method for reconstructing digital flexion, not only in lower brachial plexus injury, but also in forearm injury patients. Level of evidence: IV

Comparative Study of Ulnar-Shortening Osteotomy, Arthroscopy Wafer Procedure, and Distal Metaphyseal Ulnar-Shortening Osteotomy for Ulnar Impaction Syndrome

Purpose: To investigate the results of ulnar-shortening osteotomy, arthroscopy wafer procedure, and distal metaphyseal ulnar-shortening osteotomy for the treatment of ulnar impaction syndrome. Methods: In all, 33 cases of ulnar impaction syndrome, which were treated with ulna orthopedic surgery in our hospital from June 2011 to May 2014, were studied retrospectively. They were divided into 3 groups: group A, including 10 cases who underwent ulnar-shortening osteotomy; group B, including 19 cases who underwent arthroscopy wafer procedure; group C, including 4 cases who underwent distal metaphyseal ulnar-shortening osteotomy. Wrist functions of these cases were evaluated before the surgery and after the surgery every 3 months. The evaluations included visual analogue scale, range of motion, grip strength, and the modified Mayo wrist scores. Results: The mean follow-up period was 25 months (SD, ±14). In group A, 9 cases underwent pain relief, 1 better. In group B, 13 relief, 5 better, and 1 no improvement. In group C, 1 relief, 2 better, and 1 no improvement. Conclusions: Ulnar diaphyseal shortening osteotomy, arthroscopy wafer procedure, and distal metaphyseal ulnar-shortening osteotomy are effective surgical options of ulnar impaction syndrome. Ulnar-shortening osteotomy is reliable procedure in pain relief. The shape of the distal radioulnar joint in the midcoronal plane should be considered in the decision-making stage.

Elbow Flexion Reconstruction by End-to-Side Neurorrhaphy in Phrenic Nerve Transfer

Purpose: Phrenic nerve transfer (PNT) has proven to be an effective approach for the treatment of brachial plexus avulsion injuries (BPAI). But there have been major concerns about the possibility of deterioration of the pulmonary and diaphragm functions after PNT. In the current study, we performed end-to-side neurorrhaphy in PNT for BPAI patients while minimizing the potential damage to the diaphragm function. We prospectively assessed the efficacy of end-to-side neurorrhaphy for PNT in reconstructing the elbow flexion by regenerating the anterior division of the upper trunk (ADUT) or the musculocutaneous nerve (McN) in a series of 5 patients. Methods: From January to June 2008, 5 patients with BPAI underwent PNT with an end-to-side fashion, to regenerate the ADUT (3 patients) or the McN (2 patients). The operative delay after injury was from 1 to 6 months (mean, 2.5 months). The follow-up duration was 24 months. The regeneration outcomes of ADUT or McN were evaluated with an electromyography (EMG) test. The recovery of elbow flexion power was recorded according to the British Medical Research Council (MRC) grading system. Pulmonary function tests (PFTs) were used to assess the respiratory function. Chest fluoroscopy and phrenic nerve conduction studies were performed in the evaluation of phrenic nerve and diaphragm functions. Results: At the final visits after 2 years, all patients regained various degrees of biceps strength (M4 in 2 patients, M3 in 1 patient, M2 in 1 patient, and M1 in 1 patient). At 24 months after surgery, the average prolongation of latency of PN was 2.88 seconds, and the average decrease in amplitude from before the operation was 32.4%. The diaphragm function and PFTs were normal in all patients. Conclusions: PNT with end-to-side neurorrhaphy could provide functional biceps recovery in a majority of patients, with preservation of donor nerve function.